Asthma Guidelines for Diagnosis and Treatment

Asthma Severity Classification

Based on National Heart Blood and Lung Institute guidelines, asthma is classified into four categories depending on how severe asthma symptoms are in patients and what the degree of functional disability is in them; such features may include degree of bronchial hyper-reactivity, number of emergency visits, number of hospitalizations, pulmonary function test, impairment of activity, and medication use. These categories help tailor asthma treatment so that maximum possible relief could be provided to patients. These categories are:

  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent

The above classification is based on a four-week review of asthma symptoms and lung function measurements in patients.

Your asthma is Mild Intermittent when:

  • You have asthma symptoms less than twice a week and there is no limitation of activity.
  • Your nighttime exacerbations occur not more than twice a month.
  • Your lung function FEV1 or PEFR is more than or equal to 80% of your personal best as measured by spirometry or peak flow meter.
  • Your peak flow has less than 20% variability between high and low readings on AM-to-AM or AM-to-PM, day-to-day basis.

Your asthma is Mild Persistent when:

  • You have asthma symptoms more than twice a week but less than once a day.
  • Your nighttime exacerbations occur more than twice a month. When exacerbations occur they may affect your daily activities.
  • Your lung function FEV1 or PEFR is less than or equal to 80% of your personal best as measured by spirometry or peak flow meter.
  • Your peak flow has between 20-30% variability between high and low readings on AM-to-AM or AM-to-PM, day-to-day basis.

Your asthma is Moderate Persistent when:

  • You have daily asthma symptoms and daily use of quick relief reliever medications (ie, inhaled beta2-agonist medication). Your asthma exacerbations occur more than twice a week and may last for days.
  • Your nighttime exacerbations occur more than once a week.
  • Your lung function FEV1 or PEFR is between 60-80% of your personal best as measured by spirometry or peak flow meter.
  • Your peak flow has more than 30% variability between high and low readings on AM-to-AM or AM-to-PM, day-to-day basis.

Your asthma is Severe Persistent when:

  • You have almost continual asthma symptoms and limited physical activity.
  • You experience frequent daily and nighttime exacerbations.
  • Your lung function FEV1 or PEFR is less than or equal to 60% or less of your personal best as measured by spirometry or peak flow meter.
  • Your peak flow has more than 30% variability between high and low readings on AM-to-AM or AM-to-PM, day-to-day basis.
CLASSIFICATION OF ASTHMA SEVERITY
Severity Prior to Initiation of Therapy
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent
Symptoms < or = 2 per week > 2 per week daily symptoms continual symptoms
Nighttime symptoms < or = 2 per month > 2 per month > 1 per week frequent
Lung function

FEV1 or PEFR

> or = 80% predicted < or = 80% predicted > 60% –
< or = 80%
< or = 60%
Peak flow variability < 20% 20-30% > 30% > 30%

Please note:

All asthma symptoms above need not be present in all the cases. Usually one or two of these are sufficient for asthma classification.

When in doubt, classify yourself into the next higher category. This will avoid under-treatment. Classification of your asthma can always be reviewed after the treatment has been started. Your asthma may fluctuate from one category to another. For example, if you usually have moderate persistent asthma, you may experience occasional periods of mild persistent asthma or severe persistent asthma. Likewise, you may have nocturnal asthma for several months and then be free of nighttime symptoms for a long period.

In all categories, acute exacerbations or attacks of asthma may occur from time to time.

Step Therapy Treatment in Asthma Management based on Severity

Treatment of asthma is tailored according to the category you fall in. The goal of asthma treatment is to control asthma symptoms with as little medication as possible. Medications should change as your symptoms change. If you think your category is changing, for better or worse, contact your physician for readjustment of drugs and doses.

STEP THERAPY BASED ON ASTHMA SEVERITY
Classification Quick Relief Long-Term Control
Step 1: Mild Intermittent prn/sos (as needed) None.
Step 2: Mild Persistent prn/sos (as needed) Single agent with anti-inflammatory activity.
Step 3: Moderate Persistent prn/sos (as needed) Inhaled corticosteroids, add long-acting bronchodilator if needed.
Step 4: Severe Persistent prn/sos (as needed) Multiple long-term control medications. Add oral corticosteroids if needed.
LONG TERM CONTROL Rx QUICK-RELIEF MEDICATIONS
Corticosteroids***
Cromolyn/nedocromil**
Leukotriene modifiers**
Methylxanthines**
Long-acting beta-agonists*
Short-acting beta-agonists*
Anti-cholinergics*
Systemic glucocorticosteroids***
***Most potent and effective anti-inflammatory agents
**Some anti-inflammatory activity
*No demonstrated anti-inflammatory activity
Note:- Metered dose inhalers (MDIs) are the most effective method for inhaled drug delivery.  Use nebulizers for kids if they have problems with MDIs.
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